| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
550 |
548 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
160 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
889 |
$18K |
| D1351 |
Sealant - per tooth |
465 |
112 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
85 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
578 |
578 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
66 |
$10K |
| D1120 |
Prophylaxis - child |
300 |
300 |
$9K |
| D0274 |
Bitewings - four radiographic images |
318 |
318 |
$9K |
| D2330 |
|
99 |
46 |
$5K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$2K |
| D1310 |
|
170 |
170 |
$2K |
| D1330 |
|
168 |
168 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$240.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$200.00 |